Personality Disorders

Personality Disorders Heidi Combs, MD

Objectives: • Describe why it is important to identify personality disorders • Understand the etiology of personality disorders • Identify screening questions for personality disorders • List the key features of each personality disorder

Personality Disorders An enduring pattern of inner experience and behavior that manifests in two or more of the following: cognition (i.e., ways of perceiving and interpreting self and others); Affectivity (i.e., range, intensity, lability) ;Interpersonal functioning; Impulse control

The enduring pattern is inflexible It leads to significant distress or impairment in functioning The pattern is stable and can be traced back to adolescence or early adulthood

Why should you look for personality disorders? They are common! Prevalence estimated between 6-13% of the adult population in the United States has a personality disorder!! Recognizing personality disorders can guide your approach to them Identifying a personality disorder allows you to assess for comorbities including Axis I disorders and suicide risk Paris. J. 2010 Estimating the prevalence of personality disorders in the community. J personal dis, 24(4):405-411

Prevalence OCPD 2% Paranoid 2% Antisocial 1-4% Schizoid 1%? Schizotypical 1% Avoidant 1-2% Histrionic 2% Borderline 2-3% Dependent 0.5% Narcissistic .5-1% Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-632

Knowing how to approach these patients helps with: understanding confusion about why patients do not act as you expect them to the emotional distress they can illicit protecting you from inappropriate relationships and engaging in medical practice outside your standard of care

Etiology Likely multi-factorial like almost all other psychiatric diagnoses. Genetic and environmental factors such as chaotic home environment and abuse have been implicated in development of maladaptive behavioral patterns.

Heritability of personality disorders Torgerson, S, et al 2000 A twin study of personality disorders. Comp psych 41:416-425 Coolidge F et al. 2001 Heritability of personality disorders in childhood: A preliminary investigation. J person dis 15:33-40

Genetics of PD cont. For comparison heritability of normal personality traits is approximately 0.5 Molecular genetics studies of PDs indicate that genes linked to neurotransmitter pathways, particularly the serotonergic and dopaminergic systems are involved. Reichborn-Kjennerud T. 2010 Dialogues ClinNeurosci 12(1):103-114

? Cultural influences ? Studies have found that in Norway compared to US, Germany and UK avoidant personality 3-4X more prevalent, dependent personality 2-3X more prevalent and schizoid is 2X more prevalent. Borderline is <½ as frequent and antisocial is ½ has prevalent. Pattern exhibits increased internalization personality disorders are prevalent and externalization disorders are rarer. Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-632

Personality Disorder Clusters Cluster A: suspicious, odd Paranoid, Schizoid, Schizotypal Cluster B: dramatic Antisocial, borderline, histrionic, narcissistic Cluster C:anxious Avoidant, dependent, obsessive-compulsive

Paranoid Personality disorder A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. Suspects others are exploiting or deceiving him Preoccupied with unjustified doubts of loyalty Is reluctant to confide in others because he believes they will use the information against him

Paranoid Personality Disorder cont. Reads hidden demeaning meanings into benign remarks Persistently bears a grudge Perceives attacks on his character Recurrent suspicions regarding fidelity of spouse or sexual partner

Schizoid Personality Disorder Pervasive pattern of detachment from social relationships and restricted expression of emotion with 4 or more the following: Neither desires nor enjoys close relationships Almost always chooses solitary activities Little if any interest in sexual experiences with another person Takes pleasure in few in any activities

Lacks close friends other than first-degree relatives Appears indifferent to the praise or criticism of others Shows emotional coldness or flattened affect

Schizotypal Personality Disorder A pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behavior with 5 or more of the following: Ideas of reference Odd beliefs or magical thinking Unusual perceptual experiences including bodily illusions

Odd thinking and speech Suspiciousness or paranoid ideation Inappropriate or constricted affect Behavior or appearance that is odd or eccentric Lack of close friends other than first-degree relatives Excessive social anxiety that does not diminish with familiarity

Antisocial Personality Disorder A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by 3 or more of the following: Failure to conform to social norms with respect to lawful behaviors Deceitfulness and conning others for personal profit or pleasure

Impulsivity or failure to plan ahead Irritability or aggressiveness as indicated by repeated fights or assaults Reckless disregard for safety of self or others Consistent irresponsibility Lack of remorse There is evidence of Conduct Disorder with onset before age 15

Neuroimaging and psychopathy Study by Blair found person with psychopathic tendencies showed decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli which the author felt was suggestive of difficulties with basic forms of emotional learning and decision making. Blair R. 2010 Neuroimaging of psychopathy and antisocial behavior: a targeted review. Curr Pysch Res Feb;12(1):76-82

Borderline Personality Disorder Pervasive pattern on instability of interpersonal relationships, self image and affects and marked impulsivity as indicated by 5 or more of the following: Frantic efforts to avoid abandonment Unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

Identity disturbance Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behaviors, gestures or threats or self-mutilating behaviors Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate anger Transient, stress-related paranoia

Histrionic Personality Disorder Pervasive pattern of excessive emotionality and attention seeking indicated by >5 of the following: Uncomfortable in situations in which he is not the center of attention Interaction with others often characterized by inappropriate sexually seductive behavior Displays rapidly shifting and shallow expression of emotion

Consistently uses physical appearance to draw attention to self Has a style of speech that is excessively impressionistic and lacking in detail Shows self-dramatization and exaggerated emotion Is suggestible Considers relationships to be more intimate than they are

Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, lack of empathy as indicated by >5 of the following: Grandiose sense of self-importance preoccupied with fantasies of unlimited success, power, brilliance or beauty Believes he is special and can only be understood or should associate with other special or high status people

Requires excessive admiration Has a sense of entitlement Is interpersonally exploitive Lacks empathy Is often envious of others and believes others are envious of him Shows arrogant, haughty behaviors or attitudes

Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation as indicated by >4 of the following: Avoids social occupations that involve significant interpersonal contact Is unwilling to get involved with people unless certain of being liked Is preoccupied with being criticized in social situations

Shows restraint in intimate relationships because of fear of being shamed or ridiculed Inhibited in new interpersonal situations because of feeling inadequate Views self as socially inept and unappealing Is unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing

Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors and fears of separation as indicated by >5 of the following: Has difficulty making everyday decisions without an excessive amount of reassurance Needs others to assume responsibility for most major areas of his life

Has difficulty expressing disagreement with others because of fear of loss of approval Difficulty initiating projects on his own because of lack of self confidence Goes to excessive lengths to obtain nurturance and support from others Feels uncomfortable or helpless when alone Urgently seeks another relationship as a source of care and support when a relationship ends Is unrealistically preoccupied with fears of being left to take care of himself

Obsessive-Compulsive Personality Disorder A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness as indicated by >4 of the following: Preoccupied with details, rules, lists, order or schedules to the extent that the major point of the activity is lost Shows rigidity and stubbornness

Perfectionism that interferes with task completion Excessively devoted to work and productivity to the exclusion of leisure activity and friends Over conscientious and inflexible about matters of morals or ethics Is unable to discard worn or worthless objects even those without sentimental value Reluctant to delegate tasks Adopts miserly spending style toward self and others

Treatment Can reduce symptomatology, improve social and interpersonal functioning, reduce frequency of maladaptive behaviors and decrease hospitalizations. Always screen for comorbid psych dx If the personality disorder is ego-syntonic (eg. Antisocial and Narcissistic) it will be hard to engage the patient in treatment

Medication Treatment Increasing serotonin levels may reduce depression, impulsiveness, rumination and may enhance a sense of well being Low dose neuroleptics and mood stabilizers can may be effective in modulating affective stability

Therapy For BPD DBT, Schema-focused therapy, transference-focused therapy and Mentalization-based treatment have all been found to be effective. Therapy for other disorders limited to a small number of open labeled trials and case studies. These findings have been positive. Hadjipavlou G. Et al 2010 Promising psychotherapies for personality disorders. La Revue Can De Psychiatric 55(4):202-209

Screening for comorbid disorders Antisocial PD: Alcohol dependence and depressive disorders BPD: alcohol and drug dependence, mood disorders, anxiety disorders inc PTSD Histrionic PD: alcohol dependence, somatization disorder Avoidant PD: social phobia Any PD puts pt at higher risk than the gen population for Etoh and drug dep. Trull T et al. 2010 Revised NESARC personality disorder diagnosis: gender, prevalence, and comorbidity with substance dependence disorders. J personal Dis 24(4):412-426

The other side of the coin Personality disorders have a negative prognostic significance for Axis I disorders such as anxiety and mood disorders. Ansell E et al. 2010 The association of personality disorders with the prospective 7- year course of anxiety disorders. Psychol Med Aug 10th in press

Case 1 Ms Ellie is referred to you by her primary care MD because she is concerned she has an anxiety disorder. When the pt comes into your office she is looking down and when she shakes your hand it is very sweaty. When asked about how her relationships were in junior high she stated “terrible. I never fit in and didn’t do much with other kids because I was afraid they would judge me”.

With this information what Dx are you thinking about? Social phobia? Avoidant personality disorder? Generalized anxiety disorder? Schizoid personality disorder? What do you need to know to figure out which one if any it is? Is this circumscribed or more global, does this person have relationships with others?

You illicit the following information She has never had an intimate relationship although she would like to have one and has one friend that she has known since childhood. She is intensely afraid of of being ridiculed so works as a transcriptionist from her home and sits in the back row when she goes to church. She describes herself as “not as good as other people” and doesn’t like to do new things”. She avoids new relationships unless she “is sure they are going to like me”.

Her diagnosis Given the long standing pervasive nature of her symptoms her diagnosis is most consistent with Avoidant Personality Disorder. Social phobia tends to be very situational and GAD is less pervasive.

Case 2 Jason is a 45 year old male who comes to see you to establish primary care clinic. In the ROS he notes he has to be very careful about what he eats because “certain foods I can feel work against my system. I feel them as they are integrated into my body”. He also notes he tries to be careful about what he says “because words have power…they can change the way of things”.

With this information what is your differential diagnosis? Schizophrenia? Delusional disorder? Mood disorder with psychotic features? Schizotypal personality disorder? What do you need to know to determine which it is?

You illicit the following: He is fairly close to his family but doesn’t really have any other people in his life. He denied auditory, visual or tactile hallucinations, has no thought broadcasting or thought insertion and is able to provide organized answers although you notice he speaks in a vague way and his affect is constricted. His appearance is striking because he is wearing all yellow including his shoes, belt, hat and earring which he states “is because yellow is the color that recharges me”.

His diagnosis is most consistent with a Schizotypal personality disorder. He does not have schizophrenia because of lack of disorganization and lack of true psychotic Sx. He does have magical thinking but it is not crossing into psychosis. Other history to obtain would be whether he has a declining course over time which you often see with schizophrenia.

Case 3 You are picking up your daughter from daycare and one of the other parents engages you in conversation. He states “I see you got here 5 minutes after the cut off time to…are they going to charge you extra too? You know I think this daycare is always trying to stick it to us. I get this same thing at work. I think they purposely make the clock in times and pick up times inconvenient so they can dock you here and there. Its like a conspiracy I swear!”

With this information what is your differential diagnosis? Irritated but normal parent? Persecutory delusional disorder? Schizophrenia? Paranoid personality disorder? What would you need to find out to determine which dx is correct? Screen for psychotic sx, delusions.

You illicit the following: He goes on to tell you that its been the same story his whole life. He has been passed over for promotions at work, he can’t trust his friends any further than he can throw them and he thinks his wife is cheating on him too. With your excellent clinical skills you also find out he doesn’t actually believe there is a plot and doesn’t have any psychotic sx.

His diagnosis is most consistent with a Paranoid personality disorder. He has a pervasive distrust and suspiciousness of others but it is not to the point of a delusion and he is not psychotic.

Personality Disorders